Canyon Oaks Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Canoga Park, California.
- Location
- 22029 Saticoy Street, Canoga Park, California 91303
- CMS Provider Number
- 555822
- Inspections on file
- 56
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Canyon Oaks Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that three cognitively intact residents with diagnoses such as DM, atherosclerosis, fractures, and mixed incontinence were always incontinent of bowel and bladder and required significant assistance with toileting-related ADLs, yet their care plans did not specify the type of bowel and bladder (B&B) retraining program to be used. B&B assessments had identified each as a candidate for Prompted Voiding, Habit Training/Scheduled Voiding, or Bladder Retraining, and care plans included general goals to reduce incontinence episodes, but lacked clear identification of the chosen program and individualized approaches or interventions describing how it would be implemented. During interviews, an MDS nurse and the ADON confirmed that individualized, person-centered B&B retraining care plans had not been developed or implemented for these residents, despite facility policy requiring comprehensive, person-centered care plans based on ongoing assessments.
Three cognitively intact residents with diagnoses including DM, atherosclerosis, fractures, and mixed incontinence were assessed as always incontinent of bowel and bladder and identified as candidates for a Prompted Voiding Program, Habit Training/Scheduled Voiding, or Bladder Retraining. Their MDS assessments showed they required moderate to maximal assistance with toileting-related ADLs and were dependent for toilet transfers. Although each resident’s care plan noted incontinence and set goals to decrease episodes, none of the plans specified which bowel/bladder retraining program would be implemented or detailed individualized interventions. Interviews with an MDS nurse and the ADON confirmed there was no documentation that any toileting or retraining program had been initiated, nor that the residents had been offered, agreed to, or declined participation, despite facility P&P requiring appropriate continence services, scheduled toileting or prompted voiding as appropriate, and documentation of toileting trials in the medical record.
A resident with diabetes and severe cognitive impairment did not receive their prescribed insulin glargine at bedtime, despite their blood sugar being within the ordered parameters. Nursing staff confirmed the omission was due to not fully reading the physician's order, resulting in a failure to provide care in accordance with professional standards and facility policy.
A resident with diabetes, requiring a consistent carbohydrate diet, was served regular gelatin and pudding instead of sugar free options. Both nursing and dietary staff confirmed the desserts did not meet the resident's prescribed dietary needs, and the facility's policy for diabetic diets was not followed.
Surveyors found that clear storage cups of gelatin in the kitchen refrigerator were not consistently labeled or dated according to facility policy, with several cups either unlabeled or only marked as sugar free. The Dietary Supervisor confirmed the labeling lapse, which affected a large number of residents who receive food from the kitchen.
A CNA failed to follow perineal care procedures for a resident with frequent incontinence, using a single wet towel to clean both the front and back perineal areas without rinsing or drying, contrary to facility policy. The resident required extensive assistance due to medical conditions and was at risk for pressure injuries. The CNA acknowledged not following the correct protocol during the observed care.
A CNA failed to perform hand hygiene at required intervals while providing perineal care and assisting with wound dressing changes for a resident with cancer and incontinence. The CNA used the same towel for multiple areas, did not change gloves or sanitize hands after cleaning bowel movement, and only performed hand hygiene before starting and after discarding soiled items, contrary to facility policy.
A resident with dementia and severe cognitive impairment was prescribed Seroquel for psychosis and agitation, but the facility failed to complete required monthly behavioral symptom summaries for five months. Despite physician orders and facility policy mandating ongoing monitoring and documentation, staff did not evaluate or summarize the resident's behavioral symptoms during this period, resulting in a lack of assessment for the continued need and effectiveness of the psychotropic medication.
A resident with dementia and hypertension, prescribed Seroquel for psychosis and agitation, had an episode of physical aggression documented in an SBAR form by an LVN, but the same episode was not recorded in the MAR as required. The LVN acknowledged the error, and the ADON confirmed that accurate shift documentation of behavioral episodes is expected for residents on psychotropic medications, in line with facility policy.
The facility failed to ensure call lights were accessible and promptly responded to for residents, leading to potential delays in care. A resident with a history of falls had her call light out of reach, while another resident's active call light was ignored by the DON. Additionally, a resident with reduced mobility struggled to use the standard call light, highlighting the need for adaptive devices.
The facility failed to create comprehensive care plans for two residents, one requiring oxygen therapy and the other on multiple antibiotics for a UTI. Despite physician orders, the care plans did not address these treatments, as confirmed by staff interviews and record reviews. This oversight contravenes the facility's policy on person-centered care plans.
Two residents in the facility received insulin injections without proper site rotation, contrary to professional standards and facility policy. One resident, with impaired cognition, received repeated injections in the same abdominal area over several days, while another resident, capable of understanding, experienced similar issues. A nurse confirmed the oversight, which deviated from guidelines meant to prevent skin damage.
A LTC facility failed to replace an open medication emergency kit within the required timeframe, leading to potential risks for residents. Additionally, there was a discrepancy in the controlled medication count for a resident, and a resident did not receive their routine medication, Gemtesa, due to unavailability and documentation errors. These deficiencies highlight issues in medication management and documentation practices.
A resident with schizophrenia and depression continued to receive aripiprazole despite a PMHNP's order to discontinue it due to stable symptoms. The facility's records showed the medication was administered daily, contrary to the order, and the resident's MDS indicated no behavioral symptoms justifying its use. The DON confirmed the oversight, acknowledging the risk of unnecessary medication administration.
A facility failed to maintain a medication error rate below five percent, resulting in a 24% error rate for a resident. The LVN crushed and administered medications without a physician's order, contrary to facility policy. The resident, with no documented swallowing issues, received medications inappropriately, as confirmed by the PCP and DON.
A facility failed to prevent significant medication errors by not rotating insulin injection sites for two residents and administering expired medications to two others. Insulin injections were repeatedly given in the same area, contrary to policy, and expired insulin and eye drops were administered, violating storage and labeling protocols. These actions were confirmed by staff and highlighted in the facility's policies.
A facility failed to properly label and store medications, including a Forteo pen, insulin Lantus pen, and other medications, leading to potential risks for residents. Medications were found without open date labels or pharmacy labels, and some were expired. Staff acknowledged these issues, highlighting the importance of proper labeling and disposal to ensure medication efficacy and resident safety.
The facility failed to document food temperatures on the tray line, risking food safety for 143 residents. The ADS took temperatures of various foods but did not record some, confirmed by the DS and DON. This omission violated the facility's policy and posed a risk of foodborne illness.
A facility failed to follow infection control and safety protocols, including leaving a leftover muffin in a resident's room, not labeling oxygen tubing, and neglecting hand hygiene during wound care and medication administration. These deficiencies were observed in multiple residents, increasing the risk of infection and foodborne illness.
A facility failed to maintain a resident's Living Will in the medical record, despite the resident's Advance Directive Acknowledgement Form indicating its existence. The resident, with intact cognitive skills and requiring partial assistance, had diagnoses including atrial fibrillation and heart failure. Interviews revealed that the facility did not follow its policy to obtain and maintain the Living Will, risking the resident's end-of-life treatment preferences not being honored.
A facility failed to notify a resident's representative when a medication was no longer covered by insurance, leading to a lapse in administration. Additionally, another resident's family was not informed of a MRSA diagnosis, despite the implementation of contact precautions. These deficiencies highlight communication breakdowns in notifying family members of significant changes in residents' conditions.
A facility failed to transmit a resident's MDS assessment to CMS within the required timeframe following discharge. The resident, who had a periprosthetic fracture, osteoarthritis, and type 2 diabetes, required moderate assistance for daily activities. The MDSC and DON confirmed the oversight, acknowledging the necessity of timely submission to prevent delays in care and payment.
A resident at high risk for falls had a care plan that was not updated to reflect the need for bilateral landing mats, as required by the facility's policy. Despite the resident's severe cognitive impairment and dependency on staff, only one mat was used, increasing the risk of injury. Interviews with facility staff confirmed the lack of proper assessment and implementation of the intervention.
A resident with hearing loss was unable to communicate effectively due to a malfunctioning hearing aid, which was not reported by staff as required by facility policy. The ADON confirmed that the resident's communication was impaired, potentially delaying necessary care.
A resident with cognitive impairments and specific activity preferences was not provided with outdoor activities for two months, despite the facility's policy to cater to individual preferences. The Activity Director acknowledged the oversight, which was contrary to the resident's documented preference for outdoor activities.
A resident with a stage 2 pressure ulcer did not receive continuous treatment as required. The treatment nurse failed to notify the physician before the treatment stop date, resulting in a lapse in care. The facility's policy required contacting the physician to determine if treatment should continue, which was not done, potentially worsening the ulcer.
A resident, assessed as unsafe to self-administer medications, was found with Diclofenac Gel at the bedside, brought by a family member without proper assessment or physician's order. Additionally, the resident, at high risk for falls, had only one floor mat instead of the required two, as per the care plan. The facility's policies on medication self-administration and fall prevention were not followed, leading to potential risks.
A resident with respiratory failure and hypoxia did not receive oxygen as per the physician's order. The nasal cannula was found under the resident's gown instead of being connected, despite the oxygen concentrator being on. This oversight was confirmed by an RN and acknowledged by the DON, highlighting a deficiency in providing necessary respiratory care.
A facility failed to follow its pain management protocols for a resident with cancer and gout, resulting in missed pain assessments after changes in condition and incomplete documentation of pain evaluations. The resident experienced constant pain, but the facility did not conduct required assessments or monitor pain on specific dates, as confirmed by a registered nurse.
A facility failed to document post-dialysis assessments for a resident with end-stage renal disease, omitting vital signs and access site evaluations on two occasions. This oversight, acknowledged by the ADON, could lead to undetected complications such as bleeding, contrary to the facility's care policy.
A facility failed to act on a Consultant Pharmacist's recommendation to administer Ferrous Sulfate to a resident with anemia. The Quality Assurance Nurse did not communicate the recommendation to the physician, resulting in no action being taken. This oversight placed the resident at risk for untreated anemia, as the facility's policy requires monthly medication reviews to promote positive outcomes.
A facility failed to maintain accurate EMAR for a resident prescribed Gemtesa for overactive bladder. Between February 11 and February 19, licensed nurses inconsistently documented the medication's administration, leading to inaccurate records. The resident, with a history of Alzheimer's and Parkinson's, experienced discrepancies in medication availability and charting. Interviews revealed errors by LVNs, highlighting the importance of accurate documentation per facility policy.
A facility failed to create a person-centered care plan for a resident with gastrointestinal atony, leading to a deficiency. The resident, with diagnoses of pneumonia and cerebral infarction, required maximum assistance with daily activities. Despite a physician's order for a KUB X-ray revealing an ileus and a recommendation for increased mobility, the facility did not develop a care plan to address this condition, violating their policy.
A resident with intact cognition reported being run over by another resident's wheelchair, but the incident was not reported within the required two-hour timeframe. The LPN who received the report did not immediately inform the ADM or DON, believing it was only an attempt. The facility's policy mandates prompt reporting of all abuse allegations to ensure resident safety, but the report to the SSA was delayed.
A resident with a history of stroke, atrial fibrillation, and hypertensive heart disease experienced elevated blood pressure. The facility staff failed to notify the physician immediately and did not complete a Change of Condition Form, as required by the facility's policy.
The facility staff failed to re-check and monitor a resident's elevated blood pressure after administering Cardizem LA. Despite the resident's significant medical history, there was no documentation of follow-up monitoring, placing the resident at risk for further episodes of elevated blood pressure.
Failure to Develop and Implement Individualized Bowel and Bladder Retraining Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans for bowel and bladder (B&B) retraining for three residents who were assessed as candidates for such programs. For Resident 2, the admission record showed diagnoses including atherosclerosis of the aorta, lumbar vertebral fracture, low back pain, and mixed incontinence. The MDS documented intact cognition, a need for moderate to maximal assistance with toileting-related ADLs, and that the resident was always incontinent of bowel and bladder. A B&B continence assessment identified the resident as a candidate for Prompted Voiding, Habit Training/Scheduled Voiding, or Bladder Retraining. However, the care plan on toileting and incontinence, while noting risk for incontinence-associated dermatitis and a goal to decrease incontinence episodes, did not specify which B&B retraining program would be used or include individualized approaches or interventions describing how the program would be carried out. Resident 3’s admission and assessment information showed diagnoses including diabetes mellitus and reduced mobility, intact cognitive skills for daily decision making, and a need for maximal assistance or dependence for toileting hygiene, showering, lower body dressing, and toilet transfers. The MDS indicated the resident was always incontinent of both bladder and bowel, and the B&B assessment identified the resident as a candidate for Prompted Voiding, Habit Training/Scheduled Voiding, or Bladder Retraining. The care plan reports, initiated and later revised, documented that the resident was incontinent of bowel and bladder and set goals to decrease urinary and bowel incontinence episodes. Despite this, the care plans did not identify the specific type of B&B retraining program to be implemented and did not include individualized approaches or interventions outlining how the retraining program would be implemented. Resident 4’s records showed admission with diagnoses including atherosclerosis of the aorta, left femur fracture, and presence of a left artificial hip joint. The MDS documented intact cognition, a need for maximal assistance with toileting hygiene and showering, dependence for lower body dressing and toilet transfers, and that the resident was always incontinent of bowel and bladder. A B&B assessment again identified candidacy for Prompted Voiding, Habit Training/Scheduled Voiding, or Bladder Retraining. The care plan, which noted bowel and bladder incontinence and a goal to decrease incontinence episodes during the retraining period, did not specify which B&B retraining program would be used and did not include specific, individualized approaches or interventions. During interviews and record reviews, the MDS nurse and the ADON acknowledged that individualized, person-centered care plans addressing B&B retraining programs, including the type of program and specific interventions, had not been developed and implemented for these three residents, despite facility policy requiring comprehensive, person-centered care plans based on ongoing assessments.
Failure to Implement and Document Individualized Bowel/Bladder Retraining Programs
Penalty
Summary
The deficiency involves the facility’s failure to implement its own policies and procedures for assessment and management of urinary and fecal incontinence for three cognitively intact residents who were always incontinent of bowel and bladder. Resident 2 was admitted with diagnoses including atherosclerosis of the aorta, lumbar vertebral fracture, low back pain, and mixed urinary incontinence. An MDS showed intact cognitive skills and a need for moderate to maximal assistance with toileting-related ADLs, with total dependence for toilet transfers, and documented that the resident was always incontinent of bowel and bladder. A bowel/bladder continence assessment identified the resident as a candidate for a Prompted Voiding Program, Habit Training/Scheduled Voiding, or Bladder Retraining, but did not specify which program would be used or any individualized interventions. The care plan for toileting and incontinence risk noted a goal to decrease incontinence episodes but likewise did not identify a specific retraining program or individualized approaches. Resident 3, originally admitted with diabetes mellitus and reduced mobility, also had an MDS indicating intact cognitive skills, maximal assistance needs for toileting hygiene and showering, dependence for lower body dressing and toilet transfer, and that the resident was always incontinent of bowel and bladder. A bowel/bladder assessment again identified candidacy for Prompted Voiding, Habit Training/Scheduled Voiding, or Bladder Retraining. However, the care plan, which documented that the resident was always incontinent of bowel with a goal to decrease bowel incontinence episodes, did not specify which bowel/bladder retraining program would be implemented or outline individualized interventions or approaches for carrying out such a program. Resident 4 was admitted with atherosclerosis of the aorta, a left femur fracture, and a left artificial hip joint. The MDS documented intact cognitive skills, maximal assistance needs for toileting hygiene and showering, dependence for lower body dressing and toilet transfer, and that the resident was always incontinent of bowel and bladder. The bowel/bladder assessment identified the resident as a candidate for Prompted Voiding, Habit Training/Scheduled Voiding, or Bladder Retraining, and the care plan included a goal to decrease incontinence episodes during a retraining period. Despite this, the care plan did not specify which retraining program would be used or any individualized interventions. Interviews with the MDS nurse and the ADON confirmed there was no documentation that any bowel/bladder retraining program had been implemented for these residents, nor any documentation that the residents had been offered, agreed to, or declined participation, despite facility policies requiring appropriate continence services, scheduled toileting or prompted voiding as indicated, and documentation of toileting trials and programs in the medical record.
Failure to Administer Insulin as Prescribed
Penalty
Summary
A deficiency occurred when a resident with a history of type 2 diabetes mellitus, cerebral infarction, and long-term insulin use did not receive their prescribed insulin glargine as ordered by the physician. The resident, who had severe cognitive impairment and required significant assistance with daily activities, had a physician's order for insulin glargine to be administered at bedtime if their blood sugar was not less than 100 mg/dL. On the date in question, the resident's blood sugar was recorded at 100 mg/dL, which was within the parameters for administration, but the insulin was not given. Interviews with nursing staff revealed that the omission was due to the nurse overlooking the parameters of the order and not reading it in its entirety. Both the registered nurse and the assistant director of nursing confirmed that the medication should have been administered according to the physician's order and facility policy, which requires medications to be given as prescribed. The facility's policy also emphasizes the importance of administering medications in a safe and timely manner, in accordance with prescriber orders.
Diabetic Resident Served Non-Compliant Desserts
Penalty
Summary
A deficiency occurred when a resident with type 2 diabetes mellitus, who was on a consistent carbohydrate/no added salt diet and required substantial assistance with daily activities, was served regular gelatin and regular pudding instead of sugar free alternatives. The resident's care plan specifically indicated the need for dietary restrictions and compliance with a nutritional regimen to manage hyperglycemia. During lunch service, the gelatin provided was unlabeled, and the pudding cup was marked with an 'R', which staff confirmed indicated regular pudding. Both a Licensed Vocational Nurse and the Registered Dietician verified that the items served were not sugar free and did not meet the dietary requirements for a diabetic resident. The facility's policy on consistent carbohydrate diets, which is intended for residents with diabetes, was not followed in this instance. The Registered Dietician stated that the resident should have received sugar free gelatin and pudding in accordance with their prescribed diet. The failure to provide the appropriate diet was observed during meal service and confirmed through interviews and record review, demonstrating noncompliance with the resident's care plan and facility dietary policies.
Failure to Label and Date Prepared Gelatin in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to follow proper food handling practices by not ensuring that clear storage cups of gelatin were labeled and dated according to the facility's policy. During an inspection of the kitchen refrigerator, open food items not in their original packaging were found in clear storage cups, with several cups either unlabeled or only marked with 'SF' for sugar free. The Dietary Supervisor confirmed that 35 cups had no label and 11 were labeled 'SF', and explained that the person preparing the gelatin is responsible for labeling. The facility's policy requires that any food item removed from its original container must be labeled with the specific name of the food and the date it was opened or prepared. This deficiency had the potential to affect 142 out of 148 residents who receive food from the facility's kitchen. The Dietary Supervisor acknowledged the importance of accurate labeling for resident safety and to ensure the correct identification of food items. A review of the facility's policy confirmed the requirement for labeling and dating prepared foods, which was not followed in this instance.
Failure to Follow Perineal Care Protocol for Incontinent Resident
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow the facility's perineal care policy and procedures while providing care to a resident who was frequently incontinent of bladder and occasionally incontinent of bowel. The CNA used a single large wet towel to clean both the front perineal area and the anal/buttocks area, folding and reusing the same towel throughout the process. The CNA did not rinse or dry the resident's perineal area during the care. This method did not align with the facility's policy, which requires the use of separate towels with soap and water for different areas, as well as thorough rinsing and drying. The resident involved had a history of malignant neoplasm of the right breast, secondary malignant neoplasm of the brain, and was at risk for developing pressure ulcers or injuries. The resident was dependent on staff for toileting hygiene and required significant assistance with lower body dressing and toilet transfers. The incident was observed by surveyors, and during interviews, the CNA acknowledged awareness of the correct procedures but admitted to not following them during the observed care. The Director of Nursing confirmed the CNA's knowledge of the proper protocol.
Failure to Perform Proper Hand Hygiene During Perineal Care
Penalty
Summary
Certified Nursing Assistant 3 (CNA 3) failed to follow proper infection control practices while providing perineal care to a resident who was dependent on staff for toileting hygiene, had a history of malignant neoplasm of the breast with secondary brain involvement, and was at risk for pressure ulcers. During the observed care, CNA 3 used the same towel to clean both the front perineal area and the anal/buttocks area, refolding it to use different sections, and did not change gloves or perform hand hygiene (HH) after cleaning the resident's bowel movement. CNA 3 then assisted a treatment nurse with wound dressing changes and subsequently changed the resident's brief and clothing, only performing HH after discarding the soiled items. When questioned, CNA 3 acknowledged that she was supposed to wash her hands and change gloves after cleaning the perineal area and before touching the resident's body, new brief, or clothing, but admitted to performing HH only twice during the entire process. The Infection Preventionist confirmed that CNA 3 did not perform HH at the appropriate times as required by facility policy, specifically after contact with body fluids and before moving from a soiled to a clean body site on the same resident. Facility policies reviewed indicated that hand hygiene is the primary means to prevent the spread of healthcare-associated infections and outlined specific requirements for HH during resident care.
Failure to Monitor and Summarize Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications by not evaluating and summarizing the resident's behavioral symptoms for a period of five months while the resident was prescribed Seroquel for psychosis and agitation associated with dementia. The resident, who had severe cognitive impairment and required maximal assistance with daily activities, had a physician's order for Seroquel to be administered at bedtime for psychosis as evidenced by hallucinations or agitation leading to aggression. The order also required monitoring of episodes of psychosis, agitation, aggression, and hallucinations every shift. Despite these requirements, the facility did not complete the required monthly Psychotropic Drug Behavior Monitoring (PDBM) summaries from January through May. The last available PDBM summary was from December of the previous year. Both the Assistant Director of Nursing and the Director of Nursing confirmed that no behavioral symptom summaries were completed during this period and that the facility relied on these summaries to evaluate the effectiveness and necessity of the psychotropic medication. The facility's policy required adequate monitoring and documentation for the use of psychotropic medications, which was not followed in this case.
Failure to Accurately Document Behavioral Episodes in MAR
Penalty
Summary
The facility failed to ensure complete and accurate documentation in the Medication Administration Record (MAR) for a resident with dementia and hypertension. The resident, who had severely impaired cognitive skills and required maximal assistance with daily activities, was prescribed Seroquel for psychosis and agitation. Physician orders required monitoring and documentation of episodes of psychosis, agitation, or aggression every shift. On a specific date, a Licensed Vocational Nurse (LVN) completed an SBAR Communication Form indicating an episode of physical aggression but documented in the MAR that there were no such episodes during the same shift. During interviews and record reviews, the LVN acknowledged the documentation error, stating that the MAR should have reflected the episode of aggression. The Assistant Director of Nursing (ADON) confirmed that licensed nurses are expected to accurately document behavioral episodes in the MAR for residents on psychotropic medications, as per facility policy. The facility's policy emphasized that medical records should be objective, complete, and accurate to facilitate communication among the care team.
Failure to Ensure Call Light Accessibility and Prompt Response
Penalty
Summary
The facility failed to ensure that residents were provided with a call light within reach, which is essential for signaling the need for assistance. Resident 34, who was admitted with conditions such as atherosclerotic heart disease, muscle weakness, and a history of falls, was observed with her call light under the mattress and not within reach. This was confirmed by a Care Partner and a Registered Nurse, both of whom acknowledged the importance of having the call light accessible to prevent delays in care. The facility's policy mandates that call lights be within reach to allow residents to call for help. Resident 134, who had a history of falls and required moderate assistance for daily activities, was observed with an active call light that was not addressed by the Director of Nursing (DON) who walked by the room twice without entering. The DON admitted that the call light should have been addressed immediately to prevent delays in care. The facility's policy requires that call lights be answered as soon as possible, but no later than five minutes. Resident 395, who was admitted with sepsis, major depressive disorder, and reduced mobility, was found unable to reach the call light due to weakness in her hands and arms. The call light was under her pillow, and she demonstrated difficulty using it. A Licensed Vocational Nurse confirmed the resident's inability to use the regular call light and mentioned the availability of adaptive devices. The facility's policy states that alternative communication means should be provided for residents unable to use the standard call system.
Failure to Develop Comprehensive Care Plans for Oxygen and Antibiotic Use
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, leading to potential inadequate care. Resident 345, who was admitted with chronic obstructive pulmonary disease and acute respiratory failure, required intermittent oxygen therapy. Despite physician orders specifying oxygen administration and equipment maintenance, the facility did not create a care plan addressing the resident's oxygen use. This oversight was confirmed during interviews with a registered nurse and the Director of Nursing, who acknowledged the absence of a care plan with specific goals and interventions for oxygen use. Similarly, the facility did not develop a care plan for Resident 27's antibiotic use, despite multiple physician orders for antibiotics to treat a urinary tract infection. The resident, who had diagnoses including acute respiratory failure and type 2 diabetes, was prescribed several antibiotics, but the care plans did not reflect this treatment. The Minimum Data Set Coordinator and the Director of Nursing confirmed the lack of a care plan addressing the antibiotic administration, which is crucial for providing specific interventions related to these medications. The facility's policy and procedure on comprehensive person-centered care plans require the development of care plans based on thorough assessments and clinical decision-making. However, the facility did not adhere to these guidelines, resulting in the failure to create necessary care plans for the residents' oxygen and antibiotic use. This deficiency was identified through interviews and record reviews, highlighting the facility's non-compliance with its own policies.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to ensure that insulin injections were administered in accordance with professional standards of practice by not rotating the injection sites for two residents. Resident 76, who was admitted with diagnoses including type 2 diabetes mellitus, neuropathy, and major depressive disorder, received insulin injections repeatedly in the same area of the abdomen over several days in February 2025. This practice was contrary to the facility's policy and the manufacturer's guidelines, which require rotation of injection sites to prevent skin damage and medication errors. Similarly, Resident 111, who was admitted with type 2 diabetes mellitus and major depressive disorder, also received insulin injections in the same area of the abdomen multiple times in December 2024. Despite having the capacity to understand and make decisions, the resident's insulin administration did not adhere to the recommended practice of site rotation. The facility's policy and the medication insert instructions both emphasize the importance of rotating injection sites to avoid adverse effects such as lipodystrophy and localized cutaneous amyloidosis. During interviews and record reviews, a registered nurse acknowledged the failure to rotate injection sites for both residents, highlighting a deviation from the facility's procedures and professional standards. The facility's policies on adverse consequences and medication errors, as well as insulin administration, clearly outline the necessity of site rotation to prevent skin tissue damage and ensure proper medication administration.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to replace an open medication emergency kit within the required 72-hour timeframe. During an observation, it was noted that the kit, labeled B002, was opened on February 13, 2025, and had not been replaced by February 24, 2025. This oversight was acknowledged by RN 1, who stated that the kit should have been replaced within 24 hours, as per facility policy, to ensure emergency medications are available when needed. Additionally, there was a discrepancy in the controlled medication count for a resident, where one dose of pregabalin was missing from the medication bubble pack compared to the Controlled Drug Record accountability log. LVN 4 admitted to administering the medication but failing to document it, which is against the facility's policy. This lack of documentation could lead to medication errors and potential harm to the resident. The facility also failed to provide a resident with their routine medication, Gemtesa, for over a week due to unavailability. Despite the medication being marked as administered in the EMAR, it was confirmed by LVNs that the medication was not available during that period. This error in documentation and follow-up resulted in the resident not receiving their prescribed medication, which could have worsened their condition.
Failure to Discontinue Unnecessary Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically concerning the administration of an antipsychotic medication, aripiprazole. The resident, who had a diagnosis of schizophrenia and depression, was prescribed aripiprazole 5 mg to be administered as 2.5 mg daily. Despite a Psychiatric Mental Health Nurse Practitioner's (PMHNP) order on January 24, 2025, to discontinue the medication due to the stability of the resident's psychosis symptoms, the medication continued to be administered daily until February 18, 2025. The Minimum Data Set (MDS) for the resident, dated February 4, 2025, indicated that the resident was moderately impaired in cognitive skills for daily decision-making and had no mood or behavioral symptoms such as screaming. The MDS also noted that a Gradual Dose Reduction (GDR) was attempted on February 2, 2025, but there was no documentation from a physician indicating that the GDR was clinically contraindicated. Despite the PMHNP's note on February 7, 2025, indicating no apparent distress after discontinuing the medication, the facility's Medication Administration Record (MAR) showed that the resident continued to receive the medication daily. During a review and interview with the Director of Nursing (DON) on February 26, 2025, it was confirmed that the facility failed to discontinue the medication as per the PMHNP's orders. The DON acknowledged that the resident did not exhibit any documented behaviors that would justify the continued use of the medication, aligning with the PMHNP's orders to attempt a GDR by discontinuing aripiprazole. This oversight placed the resident at risk of receiving unnecessary psychotropic medications, which could result in adverse consequences and side effects, negatively impacting the resident's health and well-being.
Medication Error Rate Exceeds Acceptable Limit
Penalty
Summary
The facility failed to ensure that the medication error rate was less than five percent, resulting in a 24% error rate for one resident during medication administration. Six out of 25 medication opportunities were administered incorrectly to a resident, as the medications were crushed and mixed with applesauce without a physician's order to do so. The Licensed Vocational Nurse (LVN) involved acknowledged the error, stating that medications should only be crushed with a physician's order, and admitted to not contacting the physician to obtain such an order. The resident involved, who was admitted with diagnoses including dementia, atherosclerosis, and hypertension, did not have any documented difficulty swallowing. The primary care physician confirmed that there were no orders to crush the medications and was unaware of any swallowing issues. The facility's policy requires medications to be administered according to prescriber orders and specifies that medications should only be crushed when appropriate and consistent with physician orders. The Director of Nursing confirmed that the LVN failed to follow the facility's policy by crushing the medications without an order.
Significant Medication Errors in Insulin Administration and Expired Medications
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the improper administration of insulin and expired medications. Two residents, both diagnosed with type 2 diabetes mellitus, were subjected to repeated insulin injections in the same area without site rotation, contrary to the facility's policy and professional standards. This practice was observed in the medication administration records of both residents, with injections consistently administered in the left upper quadrant of the abdomen for one resident and the left lower quadrant for the other. The failure to rotate injection sites was acknowledged by a registered nurse during a review, who confirmed that this constituted a medication error. Additionally, the facility administered expired medications to two residents. One resident received a dose of expired insulin Fiasp, while another received two doses of expired latanoprost eye drops. The expired medications were found in a medication cart, improperly stored and labeled, and were administered by licensed vocational nurses. The facility's policies and procedures, as well as manufacturer instructions, were not followed, leading to the administration of these expired medications. The Director of Nursing confirmed that the facility failed to dispose of expired medications as per policy, which could result in decreased potency and effectiveness of the medications. The facility's policies on medication administration and storage were not adhered to, resulting in significant medication errors. The policies clearly outlined the need for rotating injection sites and discarding expired medications, yet these were not followed, leading to the deficiencies observed. The report highlights the facility's failure to comply with professional standards and its own procedures, resulting in potential harm to the residents involved.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to properly label and store medications in accordance with manufacturers' requirements and facility policies, leading to potential risks for residents. During an observation in Medication Room Station 2, a Forteo pen for a resident was found without an open date label, contrary to the manufacturer's instructions to discard the pen 28 days after first use. This oversight was acknowledged by RN 1, who confirmed the importance of labeling to prevent the use of ineffective medication. In Medication Room Station 1, an insulin Lantus pen was discovered without a pharmacy label, making it unclear which resident it belonged to. LVN 3 confirmed that facility policy requires all medications to be labeled with the resident's name to prevent accidental administration to the wrong resident. The lack of labeling posed a risk of medication errors and potential transmission of blood-borne pathogens. Further deficiencies were noted in Medication Cart 2 Station 4, where several medications were either improperly labeled or expired. A fluticasone and salmeterol inhalation powder device for a resident was not labeled with an open date, making it impossible to determine its expiration. Additionally, an expired Fiasp Flextouch pen and latanoprost eye drop bottle were found, both of which had been used beyond their recommended dates. LVN 5 acknowledged these issues, emphasizing the importance of proper labeling and timely disposal to ensure medication efficacy and resident safety.
Failure to Document Food Temperatures on Tray Line
Penalty
Summary
The facility failed to ensure proper documentation of food temperatures on the tray line, which is crucial for maintaining food safety standards. During an observation, the Assistant Dietary Supervisor (ADS) was noted to have taken temperatures of various food items, including soup, beef, vegetables, and others, but failed to record the temperatures of fish, cottage cheese, diced chicken, beans, and mashed potatoes. This omission was confirmed during an interview and record review with the ADS, who acknowledged that these temperatures should have been documented to ensure food safety and prevent potential foodborne illnesses. The Dietary Supervisor (DS) and the Director of Nursing (DON) both emphasized the importance of maintaining a complete Food Temperature Log to ensure that all food served is within the safe temperature range. The facility's policy, last reviewed in January 2025, mandates that food temperatures be taken and recorded before meal service. The failure to document these temperatures posed a risk to the 143 medically compromised residents who rely on the facility's kitchen for their meals, as it could lead to harmful bacteria growth and cross-contamination, potentially resulting in foodborne illnesses.
Infection Control and Safety Protocol Failures
Penalty
Summary
The facility failed to ensure proper food safety protocols were followed for a resident, identified as Resident 96, who was found with a leftover blueberry muffin from the previous day on their bedside table. The muffin was uncovered and exposed to air, which could lead to contamination and potential foodborne illness if consumed. The Dietary Supervisor confirmed that leftover food should be discarded after two hours to prevent such risks, but the muffin remained in the resident's room beyond this time frame. Another deficiency was observed in the facility's failure to adhere to their oxygen administration policy for Resident 345. The resident's oxygen tubing was not labeled with the date and time of the last change, as required by the facility's procedures. This oversight was acknowledged by both a Certified Nursing Assistant and a Licensed Vocational Nurse, who confirmed that the tubing should be changed weekly and labeled accordingly to prevent infection risks. The facility also did not comply with hand hygiene protocols during wound care for Resident 32. Treatment Nurse 2 failed to use alcohol-based hand rub after removing gloves, which is a critical step in preventing the spread of infection. Additionally, a Licensed Vocational Nurse did not perform hand hygiene before preparing and administering medication to another resident, further increasing the risk of infection spread. These lapses in infection control practices were acknowledged by the facility's Infection Preventionist and Director of Nursing, who emphasized the importance of following established hand hygiene procedures.
Failure to Maintain Resident's Living Will in Medical Record
Penalty
Summary
The facility failed to implement its policy and procedure for Advance Directives for one of the sampled residents by not obtaining and maintaining a copy of the resident's Living Will in the medical record. The resident, who was originally admitted in 2017 and readmitted later, had diagnoses including weakness, atrial fibrillation, and heart failure. The Minimum Data Set indicated that the resident's cognitive skills for daily decision-making were intact, and the resident required partial assistance for certain activities. The Advance Directive Acknowledgement Form, signed by the resident's Responsible Party, indicated that the resident had executed a Living Will and provided it to the facility. Interviews with the Social Worker and the Director of Social Services revealed that the facility did not have a copy of the resident's Living Will in the medical chart, despite the acknowledgment form indicating its existence. The facility's policy required that copies of Advance Directives be obtained and maintained in the resident's medical record in a readily retrievable location. The failure to have the Living Will in the medical chart meant that the resident's end-of-life treatment preferences might not be honored, as the staff would not be aware of the resident's wishes.
Failure to Notify Resident Representatives of Medication and Condition Changes
Penalty
Summary
The facility failed to notify the resident's representative when a resident's medication, Gemtesa, was no longer covered by insurance and before it ran out. This affected Resident 112, who had been admitted with diagnoses including Alzheimer's Disease, Parkinson's Disease, and major depressive disorder. The medication was crucial for managing urinary incontinence, and its discontinuation without notification had the potential to negatively impact the resident's care. The Licensed Vocational Nurse (LVN) documented the medication as not available and awaiting refill, but the family was not informed until several days later, leading to a lapse in medication administration. In another instance, the facility failed to notify a resident's representative of a change in condition when Resident 27 was diagnosed with Methicillin-Resistant Staphylococcus aureus (MRSA). Despite the diagnosis and the implementation of contact precautions, the family member was only informed of a urinary tract infection and a room change, not the MRSA diagnosis. This lack of communication was confirmed through interviews with staff, including Licensed Vocational Nurses and the Social Worker, who acknowledged the oversight in notifying the family about the MRSA diagnosis. The facility's policy and procedure require prompt notification of changes in a resident's medical condition to the resident, their physician, and their representative. However, in both cases, this policy was not followed, leading to deficiencies in communication and potential negative impacts on the residents' care. The failure to notify the family members about significant changes in the residents' conditions highlights a breakdown in the facility's communication processes.
Failure to Timely Transmit MDS Assessment
Penalty
Summary
The facility failed to ensure the timely transmission of the Minimum Data Set (MDS) assessment to the Centers for Medicare and Medicaid Services (CMS) system for a resident, identified as Resident 30. The resident was admitted with diagnoses including a periprosthetic fracture around an internal prosthetic left knee, osteoarthritis, and type 2 diabetes. The resident required moderate assistance for all activities of daily living and had mildly impaired cognition. Despite these needs, the MDS assessment, which is required to be completed and submitted within 14 days of discharge, was not completed or submitted to CMS following the resident's discharge. Interviews with the Minimum Data Set Coordinator (MDSC) and the Director of Nursing (DON) confirmed the oversight. The MDSC acknowledged the requirement to complete the MDS assessment upon discharge and admitted that the assessment for Resident 30 was neither completed nor submitted. The DON reiterated the necessity of submitting the discharge assessment within the stipulated timeframe to avoid delays in care and payment. The facility's failure to adhere to these requirements was identified as a deficiency, with the potential to delay services for the resident.
Failure to Revise Care Plan for Fall Risk Resident
Penalty
Summary
The facility failed to revise a resident's care plan to accurately reflect the use of floor or landing mats for a resident at high risk for falls. The resident, who was severely impaired in cognition and dependent on staff for dressing and footwear, had a history of falls and was identified as high risk for falls in a Fall Risk Evaluation. Despite this, the care plan initially included only one landing mat, contrary to the intervention added to the care plan which indicated the need for mats on both sides of the bed. This discrepancy was observed during an interview and record review, where it was noted that only one mat was being used, and there was no current order for any landing mat. The deficiency was further highlighted during interviews with facility staff, including a CNA, LVN, ADON, and DON, who confirmed the lack of proper assessment and implementation of the intervention for bilateral landing mats. The facility's policy on fall prevention and comprehensive person-centered care plans emphasized the need for thorough assessment and appropriate interventions, which were not followed in this case. The failure to update the care plan and implement the necessary interventions increased the risk of injury for the resident in the event of a fall.
Failure to Maintain Resident's Hearing Aid Functionality
Penalty
Summary
The facility failed to ensure that a resident's hearing aid was functioning properly, which impacted the resident's ability to communicate effectively. The resident, who was admitted with diagnoses including muscle weakness and hearing loss, was observed stating that her hearing aid was broken and that she could not hear. Despite the Minimum Data Set (MDS) indicating that the resident could hear adequately with a hearing aid, the resident repeatedly reported the malfunction to staff, including the Assistant Director of Nursing (ADON) and a Certified Nurse Assistant (CNA). The ADON acknowledged that the resident's ability to communicate needs to caregivers was compromised due to the malfunctioning hearing aid. The facility's policy required staff to notify a supervisor if a hearing aid was damaged, but there was no record of such a report being made to the Social Services Department. This oversight had the potential to delay necessary care, treatment, or services for the resident.
Failure to Provide Resident with Preferred Outdoor Activities
Penalty
Summary
The facility failed to provide activities according to the preferences of a resident, identified as Resident 98, which resulted in a deficiency. Resident 98 was admitted with diagnoses including hepatomegaly and benign prostatic hyperplasia. The Minimum Data Set (MDS) assessment indicated that the resident had severely impaired cognitive skills and required maximal assistance for daily activities. Importantly, the MDS noted that it was important for the resident to go outside for fresh air when the weather was good. Despite this preference, the Activity Director (AD) confirmed during an interview and record review that Resident 98 had not participated in outdoor activities for the past two months. The facility's policy on Activity Programs, which was last reviewed in January 2025, stated that activities should be designed to meet the interests and well-being of each resident based on their preferences. The AD acknowledged that outdoor activities were beneficial for the resident's well-being and should have been provided, indicating a failure to adhere to the resident's activity preferences.
Failure to Continue Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide care consistent with professional standards for a resident with a stage 2 pressure ulcer in the sacral region. The resident, who had severe cognitive impairment and required maximal assistance for daily activities, was admitted with this condition. A physician's order was in place to treat the ulcer with normal saline, zinc oxide, and a dry dressing for 21 days. However, the treatment was discontinued on the 21st day without notifying the physician, even though the ulcer had not fully healed. The treatment nurse did not inform the physician before the treatment stop date, resulting in a lapse in care from the 22nd to the 30th day. The treatment was only resumed on the 31st day and continued for six days. The facility's policy required the nurse to contact the physician one day before the treatment stop date to determine if the treatment should continue, which was not done. This oversight had the potential to worsen the pressure ulcer and lead to infection.
Failure to Prevent Medication Mismanagement and Inadequate Fall Prevention
Penalty
Summary
The facility failed to ensure that a resident, who was assessed as unsafe to self-administer medications, was not left unattended with Diclofenac Gel 1% at the bedside. The resident, who was severely impaired in cognition and dependent on staff for daily activities, was observed with the medication on the bedside table. The Licensed Vocational Nurse (LVN) and Treatment Nurse (TN) were unable to locate the medication in the medication cart, and it was revealed that the resident's family member had brought the medication to the facility. The facility's policy required an assessment and physician's order for self-administration, which was not completed for this resident. Additionally, the facility failed to provide adequate fall prevention measures for a resident at high risk for falls. The resident's care plan indicated the need for floor mats on both sides of the bed, but only one mat was observed in use. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that the resident required two landing mats due to a previous fall and the potential to fall on either side when attempting to get out of bed. The facility's policies on self-administration of medications and fall prevention were not followed, leading to potential risks for the resident. The interdisciplinary team did not assess the resident's ability to self-administer medication, and the necessary fall prevention interventions were not fully implemented, as evidenced by the observations and interviews conducted during the survey.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to provide appropriate respiratory care to Resident 136, who was admitted with diagnoses including respiratory failure with hypoxia, heart failure, and parkinsonism. The physician's order required oxygen administration at two liters per minute via nasal cannula as needed to maintain oxygen saturation above 90%. However, during an observation, it was found that the nasal cannula was not connected to the resident but was instead under the resident's gown, while the oxygen concentrator was on. This oversight was confirmed by RN 2, who acknowledged the need for oxygen administration to maintain the resident's oxygen saturation levels. The Director of Nursing confirmed that oxygen should be administered according to the physician's order to prevent the worsening of the resident's respiratory condition. The facility's policy on oxygen administration emphasized the importance of securely anchoring the tubing and ensuring the proper placement of the oxygen device on the resident. The failure to adhere to these guidelines and the physician's order resulted in a deficiency in providing necessary respiratory care to Resident 136, potentially impacting the resident's respiratory well-being.
Failure to Follow Pain Management Protocols
Penalty
Summary
The facility failed to adhere to its policy and procedure for pain assessment and management for a resident, identified as Resident 38, who was admitted with diagnoses including secondary malignant neoplasm of bone and peritoneum, and gout. The resident's Minimum Data Set (MDS) indicated that they experienced almost constant pain over a five-day period and were dependent on staff for various activities of daily living. Despite this, the facility did not conduct pain assessments following changes in the resident's condition on two occasions, specifically on 12/8/2024 and 2/13/2025, when the resident experienced new or worsening pain. Additionally, the facility did not thoroughly complete the Pain Risk Evaluation form for Resident 38 on 12/30/2024. The form failed to include the names of both scheduled and PRN medications used for the resident, which is a requirement for a complete assessment. Furthermore, the facility did not monitor the resident for the presence of pain on two specific dates, 2/7/2025 and 2/23/2025, during the evening shift, as indicated by the absence of entries in the Medication Administration Record (MAR). During an interview, a registered nurse confirmed these deficiencies, acknowledging that the licensed staff did not develop and complete pain risk evaluations after the resident's changes in condition and failed to document pain monitoring as required. The facility's policy mandates comprehensive pain assessments upon admission, quarterly, and whenever there is a significant change in condition, which was not followed in this case.
Failure to Document Post-Dialysis Assessments
Penalty
Summary
The facility failed to complete the Hemodialysis Communication Record for a resident requiring dialysis services, specifically omitting post-dialysis assessments of the access site and vital signs. This deficiency was identified during a review of the resident's records and an interview with the Assistant Director of Nursing (ADON). The resident, who was admitted with end-stage renal disease and impaired cognitive skills, had an order for dialysis treatment three times a week. However, on two specific dates, the required post-dialysis assessments were not documented, which is a critical step in monitoring for potential complications such as redness, swelling, drainage, or prolonged bleeding at the access site. The ADON acknowledged the importance of these assessments, noting that failure to perform them could lead to undetected complications, potentially resulting in negative outcomes like bleeding and hemorrhage. The facility's policy on the care of residents with end-stage renal disease, last reviewed in January 2025, mandates adherence to recognized standards of care, including post-dialysis assessments. The omission of these assessments represents a deviation from the facility's established procedures and places the resident at risk for serious health issues.
Failure to Act on Pharmacist's Recommendation for Anemia Treatment
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist's recommendation for a Medication Regimen Review (MRR) was discussed with the physician and acted upon for a resident diagnosed with anemia. The Consultant Pharmacist recommended administering Ferrous Sulfate, an iron supplement, to stimulate erythropoiesis. However, the Quality Assurance Nurse (QAN), responsible for communicating these recommendations to the physician, did not discuss this recommendation with the physician, as there was no documentation indicating that the recommendation was acted upon or that the physician disagreed with it. The resident, who was originally admitted in 2020 and readmitted later, had a diagnosis of anemia, among other conditions. The resident required maximal assistance with daily activities and had the ability to communicate and understand others. The facility's policy requires the Consultant Pharmacist to review each resident's medication regimen monthly to promote positive outcomes and minimize risks. The failure to communicate the pharmacist's recommendation placed the resident at increased risk for untreated anemia, which could lead to complications such as fatigue and weakness.
Inaccurate EMAR Documentation for Resident's Medication
Penalty
Summary
The facility failed to maintain accurate electronic medical administration records (EMAR) for a resident, identified as Resident 112, who was prescribed Gemtesa for overactive bladder. The deficiency occurred between February 11, 2025, and February 19, 2025, when licensed nurses did not accurately chart the administration of the medication. The EMAR showed discrepancies where some nurses marked the medication as administered, while others indicated it was on hold due to unavailability. This resulted in inaccurate documentation in the resident's medical record. Resident 112, who was admitted to the facility on June 15, 2023, had a medical history that included Alzheimer's Disease, Parkinson's Disease, major depressive disorder, and a history of falling. The resident's physician had noted improvement in bladder spasms and urination when on Gemtesa, and the medication was to be continued. However, the EMAR entries showed inconsistencies, with some nurses marking the medication as given when it was not available, and others indicating it was on hold due to awaiting a refill from the pharmacy. Interviews with the involved licensed vocational nurses (LVNs) revealed that the medication was not available on certain days, yet it was mistakenly documented as administered. LVN 8 and LVN 9 admitted to errors in charting, acknowledging the importance of accurate documentation. LVN 4 confirmed the medication was unavailable on specific dates and had informed the resident's family about the issue. The facility's policy and procedure on charting and documentation emphasized the need for objective, complete, and accurate records, which was not adhered to in this case.
Failure to Develop Comprehensive Care Plan for Resident with Ileus
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident with gastrointestinal atony, which is a condition where the stomach cannot contract normally, leading to delayed movement of food. This deficiency was identified during a review of the resident's records and interviews with facility staff. The resident, who was originally admitted in October 2023 and readmitted in December 2023, had diagnoses including pneumonia and cerebral infarction. The Minimum Data Set (MDS) indicated that the resident had intact cognition but required maximum assistance with various activities of daily living. On December 14, 2023, a physician's order was made for an immediate KUB X-ray to assess the resident's abdominal pain, which revealed an ileus. The physician was informed of the results and recommended increased mobility for the resident. However, during a review conducted in July 2024, it was found that the facility had not developed a comprehensive care plan to address the resident's ileus condition. This oversight was contrary to the facility's policy, which mandates the creation of a comprehensive, person-centered care plan with measurable objectives and timetables for each resident.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to adhere to its policy and procedures for reporting a reasonable suspicion of a crime, specifically in the case of a physical abuse allegation involving two residents. Resident 1, who had intact cognition, reported to the Social Service Director and Director of Nursing that Resident 2 ran over him with her wheelchair. This incident was reported to have occurred on 6/8/2024, but the initial report was not made within the required two-hour timeframe. Licensed Vocational Nurse 1, who was informed of the incident by Resident 1, did not report it to the Administrator or Director of Nursing immediately, as she believed it was only an attempt and not an actual incident of abuse. The facility's policy requires that all abuse allegations, whether attempted or actual, be reported within two hours to ensure resident safety. However, the allegation was not reported to the State Survey Agency until 6/10/2024, which was beyond the required timeframe. The facility's policy on abuse, neglect, exploitation, or misappropriation, last revised in 9/2022, mandates that all reports of resident abuse be reported to local, state, and federal agencies and thoroughly investigated. The failure to report the incident promptly had the potential to delay necessary actions to protect the residents.
Failure to Notify Physician of Elevated Blood Pressure
Penalty
Summary
The facility staff failed to notify the physician immediately of a change in condition for a resident who experienced an episode of elevated blood pressure. The resident, admitted with diagnoses including cerebral infarction, atrial fibrillation, and hypertensive heart disease with heart failure, had a blood pressure reading of 193/93. Despite this significant elevation, there was no documented evidence that the physician was notified or that a Change of Condition Form was completed. The Director of Nursing confirmed that the licensed nurse should have notified the physician and completed the necessary documentation upon identifying the elevated blood pressure. The resident's Medication Administration Record indicated that the elevated blood pressure was recorded, and the prescribed medication, Cardizem LA, was administered. However, the lack of immediate notification to the physician and the absence of a Change of Condition Form were identified as deficiencies. The facility's policy requires prompt notification of the physician and the resident's representative in the event of a change in medical condition, which was not adhered to in this instance.
Failure to Monitor Elevated Blood Pressure
Penalty
Summary
The facility staff failed to re-check and monitor a change in condition for one resident who experienced an episode of elevated blood pressure. The resident, admitted with diagnoses including cerebral infarction, atrial fibrillation, and hypertensive heart disease with heart failure, had a blood pressure reading of 193/93. Despite administering Cardizem LA as prescribed, there was no documented evidence that the resident's blood pressure was re-checked and monitored 30 minutes to an hour after administration to determine the medication's effectiveness. During an interview and record review, the Director of Nursing confirmed the absence of documentation indicating that the resident's blood pressure was monitored following the administration of the medication. The facility's policy on hypertension management emphasizes the importance of monitoring and documenting blood pressure trends and isolated elevations. The failure to follow this protocol placed the resident at risk for further episodes of elevated blood pressure due to the lack of immediate medical treatment and intervention.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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